Psychotherapy Brown Bag

We know personality influences drinking behavior...but can drinking behavior influence personality?

by Michael D. Anestis, Ph.D.

I came across an interesting study this morning in the new issue of the Journal of Abnormal Psychology.  The authors - Patrick Quinn, Cynthia Stappenbeck, and Kim Fromme of the University of Texas - examined an interesting hypothesis: that in addition to the well-known impact of personality on drinking behavior (e.g., certain personality traits correspond with an increased likelihood of heavy drinking later on), drinking behavior during college might actually predict changes in particular components of personality. 

This is important for a number of reasons.  First off, it would indicate that, although personality is generally quite stable and involves a substantial amount of genetic inheritance, it remains pliable enough to shift in response to particular behavioral patterns.  In other words, certain aspects of "who a person is" might actually change over time due to particular experiences.  Secondly, it would significantly increase the degree to which cross-sectional studies of personality variables are limited in what they tell us, as studies that only look at personality and associated behaviors at one time point would have a tougher time making the argument that we can assume the directionality of their findings (e.g., that personality leads to behaviors and not vice versa).

The authors spent a decent amount of time in their introduction section discussing the corresponsive principle (Caspi et al, 2005) and included a particularly useful quote: "the most likely effect of life experience on personality development is to deepen the characteristics that lead people to those experiences in the first place" (p.470 from Caspi et al citation above).  In other words,  behaviors (e.g., heavy alcohol use) are likely to influence the components of personality that increase the likelihood of individuals engaging in those behaviors (e.g., impulsivity, sensation seeking) rather than other personality variables either unrelated or only loosely related to the onset of the behavior (e.g., autonomy).

Participants in this study were part of an impressive longitudinal study looking at dysregulated behaviors from the end of high school through college. 2,247 students between the ages of 17 and 19 filled out a survey about their high school personality and behaviors just prior to the onset of college and then two additional surveys each academic year for three years (plus one during their senior year).  The initial sample was larger, but only those randomized to complete the assessments relevant to this study were included.  The authors hypothesized that higher levels of impulsivity and sensation seeking (see my earlier articles on the UPPS-P for a better understanding of these variables) would predict increased levels of heavy drinking.  Importantly, however, they also predicted that heavy drinking would predict increases in impulsivity and sensation seeking despite what they anticipated would be a very small amount of average change in these variables across the sample.  Taking this a step further - to test the specificity of the effect of heavy drinking on personality variables related to that behavior, they anticipated that autonomy would not predict heavy drinking and that heavy drinking would not predict future increases (or decreases) in autonomy.  Finally, in order to ensure that significant findings did not simply represent the idea that being affiliated with other same-sex peers who drink in a manner consistent with their own drinking account for personality changes (e.g., ensure it was the drinking and not the social group that predicted personality change), the authors also tested whether social group drinking norms better accounted for the results.

Impressively, all of the results supported the authors stringent hypotheses.  Not surprisingly, high levels of impulsivity and sensation seeking predicted heavy drinking in college whereas autonomy did not.  More importantly, heavy drinking in college predicted later increases in impulsivity and sensation seeking despite that fact that, on average, participants' levels on these variables did not change throughout the study.  In other words, most individuals remained essentially the same personality-wise, but for those who did see shifts, heavy drinking often preceded the change and accounted for a significant portion of the variation from prior levels.  The idea that behavior can impact personality is not entirely new, but such a well designed empirical test of the possibility is great to see and offers inspiration for slew of future studies (I've already had a few churning in my head this morning).  As expected, heavy drinking did not predict changes in autonomy, meaning that behavior doesn't impact the entirety of an individual's personality, but rather is likely restricted to influencing components of personality that are directly related to the behavior.  Finally, the authors found no empirical support for the notion that these findings might be better accounted for by peer drinking norms.

Something to keep in mind here - and the authors were careful to point it out - is the age range.  The authors chose this age group with good reason: personality varies across the lifespan (in some ways) but particular age groups see more change than others.  In other words, the argument here is not that the relationships would be the same in all samples, but rather that this transactional pattern may be a good fit for college-aged individuals.

Overall, I think this study is hugely important.  Granted, a lot of the work I do looks at the relationship between personality variables and dysregulated behaviors, so it has serious implications for my work likely to impact my view of its importance, but I don't think that's the only reason I'm drawn to its results.  What do you think about these findings?  Do you see any holes in the arguments?  Do you think this pattern would hold true across a wide range of behaviors?

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If you would like to learn more about this or other topics discussed on PBB, we recommend that you consult our online store for scientifically-based psychological resources.

Dr.Mike Anestis is a post-doctoral fellow with the Military Suicide Research Consortium

References in this text

Caspi, A., Roberts, B.W., & Shiner, R.L. (2005).  Personality development: Stability and change.  Annual Review of Psychology, 56, 453-484.

Quinn, P.D., Stappenbeck, C.A., & Fromme, K. (2011).  Collegiate heavy drinking prospectively predicts change in sensation seeking and impulsivity.  Journal of Abnormal Psychology, 120, 543-556.

Moderatedrinking.com - Examining the impact of a new online intervention

by Michael D. Anestis, M.S.

I'm a big fan of innovations in health care aimed towards reaching broad groups of individuals in need and helping them meet their health goals.  The bottom line is that a large proportion of individuals in need of mental health care do not have access to effective treatments for a variety of reasons (e.g., unable to travel to treatment center, no treatment centers in area offering evidence-based care) and others have access but choose not to use it.  Interventions capable of reaching these individuals and engaging them in treatment offer immense potential value.  Recently, I wrote a PBB post about telehealth treatment for PTSD and today I want to discuss another technology-based treatment: moderatedrinking.com.  

In an article published in the current issue of the Journal of Consulting and Clinical Psychology by PBB guest author Reid Hester, Harold Delaney, and PBB guest author William Campbell, the authors described an effectiveness trial comparing their new program in combination with moderation management (MM) - another online treatment tool - to MM on its own in the treatment of problem drinking.  The study included follow-ups at 3, 6, and 12 months post-baseline, allowing for an analysis of sustained benefits.

The authors had two central hypotheses:

1. Both groups would demonstrate reductions in alcohol-related problems and drinking at follow-ups
2. The individuals using moderatedrinking.com as well as MM would exhibit greater reduction in alcohol-related problems and drinking relative to individuals only using MM.

Importantly, the goals of this trial were very specific.  The authors were not claiming that individuals with severe mental illnesses would benefit from treatment or that individuals with alcohol dependence would be treated effectively through the protocol.  Rather, they were aiming to help individuals with moderate drinking problems looking to decrease the problems in their lives associated with that particular behavior.  The authors had detailed inclusion (must have in order to participate) and exclusion (must not have in order to participate) criteria:

Inclusion criteria:

1. A score on the Alcohol Use Disorder Identification Test (AUDIT; Saunders, Aasland, Babor, de la Fuente, & Grant, 1993) greater than 7
2. Self-report that the individual is drinking at least 10 standard drinks per week during the past 30 days
3. Individual is not currently abstaining from alcohol
4. Individual expresses an interest in moderate drinking
5. Individual is at least 21 years old
6. Individual has a computer with internet access at home

Exclusion criteria:

1. History of treatment for substance abuse
2. Already member of MM
3. History of hospitalization for alcohol or drug dependence or detoxification
4. Past or current diagnosis of drug abuse or dependence
5. Evidence of past or present physical dependence
6. Current indication of psychosis or bipolar spectrum disorder
7. Evidence of significant cognitive impairment from brain dysfunction
8. Evidence of health-oriented contraindications to any further drinking
9. English reading below 8th grade level
10. Unwilling/unable to attend follow-ups
11. Unwilling/unable to provide significant other to corroborate self-report of drinking

Now, you might look at these criteria and think "hey, they're exclusing a lot of people who need treatment for alcohol use disorders!"  You're right...and the authors are up front about that.  Again, the point here is not that this treatment is going to be the best thing for everyone, but rather that, for individuals with only moderate problems with drinking, an online intervention might enable them to attain moderation in their behavior and improvement in a range of important variables.  Given that many of these individuals are not going to seek or be referred to more intensive treatment programs, either because they do not meet diagnostic criteria for dependence or because abstinance, which is the sole focus in most treatments, is not their goal, this provides a potential opportunity to use technology to reach an underserved population in need of help.

In total, 40 individuals were randomly assigned to the moderatedrinking.com + MM group and 44 were randomly assigned to the MM only group.  30 participants from the moderatedrinking.com + MM group were assessed at all four time points and 29 from the MM only group were assessed at all four time points.  Here's what they found:

Looking at both groups together, they found significant improvement from baseline through 12-months post-baseline, with evidence for increased improvement from 6 to 12 months post-baseline (meaning that the effects not only held over time, but actually continued to improve).  At baseline, participants, on average, were at the 54th percentile for women and 65th for men.  At 12 months, they were at the 29th for women and 38th for men.  Reduction in overall alcohol consumption was significant, as were increases in percentage of days abstinant and decreases in number of drinks per drinking day and blood alcohol content (BAC) on drinking days.  More specifically, average drinks per drinking day dropped from 5.35 at baseline to 3.28 at 12 months and BAC on drinking days dropped from 102 mg% to 58 mg%.

Looking at the groups separately, improvement from baseline to average at follow-ups was twice as large in the moderatedrinking.com + MM group than in the MM group.  That being said, while the improvement was significantly greater in the combined group than in the MM only group at 3 months, that difference was non-significant at the other follow-ups (meaning the two groups did not differ on level of improvement at those times).  Additionally, individuals in the combined group demonstrated a greater improvment in the number of days abstinent from alcohol than did folks in the MM only group.  Finally, lighter drinkers in the combined group had better outcomes in terms of BAC on drinking days than did folks in the MM only group, but heavier drinkers in the combined group did not have significantly better results.  This last result further supports the notion that this treatment option is not aimed at individuals with severe alcohol use problems, but rather individuals who are developing problems and would like to adjust their behavior and its associated outcomes.

Okay...I threw a lot of results at you there (and there are some I left out).  The overall point here from this study is that there is some compelling preliminary evidence that a new online intervention can, in combination with another online resource, prove incrementally useful for non-severe problem drinkers.  Again, I love that this study uses technology to reach individuals outside of the clinic.  As much as I love the idea of people in need of mental health care travelling to local clinics to receive evidence-based care, that simply is not realistic in a lot of cases, so programs like this offer another potential method of providing evidence-based care to large groups of people in need.

As I write this, I am aware that the goal of this program - and, in fact, the name itself - may seem odd to some readers.  After all, isn't abstinance the only goal in alcohol use treatment?  The short answer is that the evidence says differently - that for those who seek moderation as an outcome, this is, in fact, an attainable goal.  Keep in mind, however, that neither PBB nor moderatedrinking.com is proclaiming abstinance from drinking to be a bad goal or that all individuals with alcohol use disorders can attain a healthy level of moderate drinking.  This is simply one means towards attaining one goal that could fit for certain individuals.

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If you would like to learn more about this or other topics discussed on PBB, we recommend that you consult our online store for scientifically-based psychological resources.

Mike Anestis is a psychology resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology program at Florida State University

Beliefs about suicide in depressed individuals with alcohol use disorders

by Michael D. Anestis, M.S.

Right now, I'm approximately two-thirds of the way through the portion of my Abnormal Psychology course during which I teach my students about suicide.  As I have mentioned on PBB many times before, suicide is topic plagued by misinformation and, as a result, I spend a good portion of this lecture discussing specific studies that refute commonly held but mistaken beliefs about suicide (e.g., suicide is an impulsive behavior, assessing for suicide risk causes people to become suicidal).  In today's lecture, I spent a bit of time talking with my students about the fact that religious and cultural beliefs that discourage suicide are considered by many to be a protective factor, meaning that maintaining such beliefs indicates a lower risk that an individual will attempt and die by suicide.  As we talked about this, I cautioned them not to leap to conclusions about the meaning of that data, as other factors often better explain the relationship between two variables.

Today, I would like to describe a study conducted by Randall Richardson-Vejlgaard and colleagues at the Columbia University College of Physicians and Surgeons and the Columbia University School of Social Work that was published in late 2009 in the Journal of Affective Disorders.  In this study, the authors looked at view of suicide in depressed individuals with and without alcohol use disorders (AUDs).  Their goal was essentially to see if those with AUDs maintained different views towards suicide than individuals without AUDs and whether those views were related to suicidal ideation and behavior.

To do this, this authors recruited a sample of 521 participants diagnosed with depression (73% of sample) or bipolar disorder (currently in the depression phase; 27% of sample) as determined through a structured diagnostic interview.  42% of the sample reported a past history of AUD and 50% had attempted suicide in the past.  60% of the sample with a history of AUDs had a previous suicide attempt compared to 42% of the non-AUD sample. 

The key finding in this study, as indicated by the authors, was that individuals with AUDs had fewer moral objections to suicide than did individuals without AUDs.  Additionally, a lack of moral objections to suicide was associated with higher levels of suicidal ideation and prior suicidal behavior.  The authors were careful not to overstate the implications of their findings, but the general assumption was that the lack of moral objections facilitates suicidal behavior in individuals with AUDs.  Certainly this viewpoint is worthy of consideration; however, I found myself a bit frustrated by the data and conclusions here.

In order to determine whether or not one variable explains the relationship between two others (statistical mediation), there are very specific procedures that can be conducted.  In this case, to test whether having fewer moral objections to suicide explains why individuals with AUDs report more lifetime suicide attempts, the authors simply needed to run a specific analytical procedure; however, this test was not run.  Because of this, we can see that these variables are related, but we can not tell whether or not one explains any of the others.  In this situation, we are left to simply make educated guesses, which is a dangerous game when we are discussing suicide, as so many misguided beliefs are so prominent.  Given that the individuals in this sample with AUDs had a higher rate of bipolar disorder relative to those without AUDs, it is entirely possible that the greater degree of severe mental illness accounted for all of these findings.  The authors did not control for diagnostic status, however, so we can not know for certain whether or not that is the case.

Let me explain what I mean with these issues more directly.  One interpretation of the data here is that depressed individuals with AUDs report greater levels of suicidal ideation and behavior because they have fewer moral objections to the behavior and, as such, have fewer reasons to choose alternative options.  Another interpretation, however, is that moral obligations to the behavior fade as the behavior itself occurs, and that individuals may have changed their views (and started drinking) after they made an attempt.  In other words, it would be difficult to find a sample of individuals who have repeatedly engaged in a behavior and admitted to that who also report that they are morally against it.  As such, "moral objections" could simply represent an untested theory on the part of individuals who have not yet been faced with that situation and lower objections could simply be a way for individuals to adapt their viewpoints to be more consistent with their reality.

Yet another interpretation, and one I tend to favor, is that moral objections to suicide (particularly when measured using the specific scale used in this study) tend to be a proxy measure for religiosity.  As we discussed in an earlier PBB article (click here to read the article), data indicate that the reason religiosity and its associated beliefs are protective against suicidal behavior is that the individuals who tend to maintain such beliefs also tend to be a part of a tight nit community.  When individuals maintain highly religious beliefs but do so only in private (e.g., through private prayers or meditation), they are no less likely to think about suicide or to engage in suicidal behavior than are individuals without such beliefs; however, when individuals with high levels of religiosity engage in public worship (e.g., regularly attend church services), they are, in fact, protected.  Such data - and there is much, much more to that study - indicate that it is not the beliefs themselves that impact the behavior, but rather the social support inherent in being a part of a community.  Taking it a step further, in another prior PBB article (click here to read the article), I detailed data that indicates that individuals who tend to drink heavily while alone are more prone to suicidal ideation and that individuals who engage in solitary heavy drinking tend to do so in an effort to cope with negative emotions. So, if individuals with AUDs tend to have fewer moral objections to suicide, this might actually represent a tendency to be less active with respect to public worship.  As such, they be more inclined to become isolated and to drink alone (as they do not have social support to help them deal with negative emotions), which is also associated with suicidal ideation.

My point here is not to dismiss the findings of Richardson-Vejlgaard and colleagues (2009), but rather to point out that, when we think about suicide and the risk factors that contribute to such behaviors, we have to be careful not to leap to conclusions.  Richardson-Vejlgaard et al (2009), in fact, did not jump to conclusions.  They were very modest in their interpretation of the data, but the study nonetheless represents a good teaching point in data analysis and suicide.  Much like the link between impulsivity and suicide is indirect (e.g., suicide itself is not an impulsive behavior, but impulsive people are more likely to attempt and die by suicide), moral objections to suicide might be only indirectly related to suicidal outcomes (e.g., moral objections indicate membership in a tight nit religious community, which offers social support, which lowers suicide risk).  If we overlook that point and assume the link is direct, we can lose sight of the importance of social support, overstate the importance of viewing suicide in a particular manner, and ultimately further stigmatize individuals who attempt and die by suicide (or even those who devote their lives to preventing suicide but do not see it as a sin or a sign of weakness). Ultimately, what matters here are the facts, and the data thus far seem to indicate that we need to consider the role of religion in suicide a bit differently than many have in the past.

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If you or anyone you know are experiencing thoughts of suicide, we encourage you to call 1-800-273-TALK or to find somebody to take you to the emergency room.

If you would like to learn more about suicide, we encourage you to read the following items, each of which is available through our online store for scientifically-based psychological resources:

• Why People Die by Suicide by Thomas Joiner
  

• The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients by Thomas Joiner, Kim Van Orden, Tracy Witte, and David Rudd
  

• Treating Suicidal Behavior: An Effective, Time-Limited Approach by David Rudd, Thomas Joiner, and Hasan Rajab

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Guest Article - Impediments to progress in psychotherapy and new ways to address them

by William Campbell, B.A. and Reid Hester, Ph.D.

Clinicians who don’t regularly treat patients with alcohol use disorders might be surprised to discover that one quarter of all clinical patients engage in heavy, problematic drinking. Even clinicians who are well aware of their patient’s misuse of alcohol often struggle with how to incorporate a treatment of the drinking behavior into their overall therapeutic plan. This is important, because unless clinicians have assessed and accounted for their client’s drinking habits, they may not suspect that a “hidden” behavior is inhibiting the course of treatment.

When most of us think of evidence supported treatments for substance abusing clients, we probably think of intensive motivational and behavioral regimens like the Community Reinforcement Approach and Motivational Interviewing, usually for severely dependent clients. But what about less dependent or abusive drinkers, who for one reason or another are struggling to control their drinking, but otherwise have no desire to quit? What treatments exist for them? This question is especially pressing in light of the fact that the vast majority of people struggling with their drinking belong to this latter group; they account for the larger proportion of the costs to society associated with alcohol abuse and, as a group, they tend to have much better treatment outcomes than more dependant drinkers. Epidemiological research suggests that there are four times as many individuals with alcohol problems with no evidence of dependence relative to those who meet the criteria for dependence (NIAAA, 2000). Furthermore, a recent report indicates that this group is increasing in size while the prevalence of alcohol dependence is declining (NIAAA, 2004).

With just such a treatment population in mind, Dr. Reid Hester has been working since the early 1990’s on interventions to help struggling drinkers moderate their consumption, specifically through the use of computer and internet-based interventions. Dr. Hester has developed programs like Drinker’s Check-up that combine assessment and feedback to help people curious about the severity of their drinking get an accurate idea of how they relate to other people with similar problems. More recently Dr. Hester developed the intervention Moderate Drinking (MD), that combines a similar assessment process with a self-directed intervention based on the methods of Behavioral Self-Control Training (BSCT). BSCT is a behaviorally focused protocol that utilizes elements of self-assessment, monitoring, goal setting, and the exploration of drinking “triggers” to help self-motivated drinkers either regain control of their habit, or find their way to abstinence. BSCT, delivered in various formats, has been tested in more clinical trials than any other intervention devoted to alcohol problems, and its efficacy has been consistently supported by this research. As one prominent researcher noted, "BSCT has become the standard moderation-oriented treatment” (Heather et al., 2000).

Funded by NIH, we recently conducted a randomized clinical trial with 80 heavy drinkers to test MD’s effectiveness. Participants randomly assigned to the experimental group had access to both the MD program and use of the resources of Moderation Management (MM), an on-line support-group for people wishing to change their drinking. Those in the control group were enrolled in MM but did not have access to the MD program. We hypothesized that both groups would reduce their drinking and alcohol-related problems and those who had access to the MD program would have better outcomes than the control group.  And they did (Hester, Delaney, Campbell, & Handmaker, 2009).

At 3-month follow-up, individuals in both groups reduced how much they drank per drinking occasion, as well as reducing how intoxicated they got on those occasions by drinking more slowly.  What’s more, the participants with access to the MD program actually drank on fewer days. They also reported a greater reduction in the following alcohol related problems compared to the control group: physical and psychological health; interpersonal issues; and taking care of one’s responsibilities.

There was a notable exception: binge drinkers, who are defined by the NIAAA as having 4-5 drinks on average per occasion, did not do as well in either group—an indication that the degree of severity of abuse may moderate success in a self-directed protocol like BSCT. However, the corollary is not true, in that severity of clinical distress, as measured by the Brief Symptom Inventory, was not a mediator of drinking outcome.  In other words, the level of psychological distress in our study participants did not have a negative impact on their success with changing their drinking.

This latter finding has a direct implication for clinical practice. Clinicians with depressed or anxious clients, who happen also to be struggling with their drinking, ought to explore the possible benefits of referring their clients to Moderate Drinking or other available BSCT protocols. Behavioral programs like the one employed by MD can be helpful to therapists because of the clarity of their therapeutic targets, and the client will have direct tie-ins between the companion motivational and affective exercises and the work done in session. Assigning such “homework” might help clients get a handle on their drinking, increase their sense of self-efficacy, and enhance the overall course of therapy.

We have completed our 12 month follow-ups and are currently preparing a manuscript that reports those outcomes. Twelve months is the minimum time period to examine long-term outcomes because relapse rates flatten out by that time. Stay tuned.

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If you would like to learn more about this and other topics discussed on PBB, Psychotherapy Brown Bag recommends that you consult their online store of scientifically-based psychological resources.

William Campbell is enrolled in the clinical psychology doctoral program at the University of New Mexico and works as a research assistant at Behavior Therapy Associates

Dr.Reid Hester, a long time investigator of substance use disorders, is Director of the Research Division at Behavior Therapy Associates in Albuquerque, New Mexico.

Drinking alone and thinking of death

by Michael D. Anestis, M.S.

A substantial proportion of the population consumes alcohol on occasion.  Of those individuals, only a small number eventually develop a substance use disorder (SUD), although even that small percentage is troubling enough to deserve diligent research attention.  The question that a situation like this raises is: of those who drink, who is most vulnerable to problematic outcomes? A number of variables could theoretically impact the answer to that question, including a family history of substance use disorders, the presence of mental illness, the context within which an individual drinks, and an individual's motivation for drinking.  Drinking motives are a particular interest of mine and you might recall from our previous discussion of Cooper's Drinking Motives Questionnaire that some researchers have broken drinking motives into three distinct categories:

1. Drinking to cope with negative emotions
2. Drinking to enhance positive emotions
3. Drinking for social reasons

In that discussion, we mentioned that drinking to cope with negative emotions is most predictive of alcohol use problems.

A similar line of research has considered the impact of drinking alone versus drinking in social contexts.  Such studies have found that individuals who engage in solitary heavy drinking are more likely to be depressed and to experience alcohol use problems than are individuals who engage in social heavy drinking (Christiansen et al., 2002).

In a study published in Addictive Behaviors by Vivian Gonzalez, Lorraine Collins, and Clara Bradizza (2009) of the Research Institute of Addictions and the University of Buffalo, the authors sought to combine these lines of research to develop a better understanding of how drinking context (e.g., alone versus socially) and drinking motives (e.g., drinking to cope versus drinking for social reasons) related to depression and suicidal ideation.  To do this, they recruited 91 underage college drinkers between the ages of 18 and 20.  All participants reported drinking at least four alcoholic beverages within the past month and positively endorsed the item "in the past, have you thought it would be better if you were not alive."  These inclusion criteria ensured that all participants were drinkers and that they had experienced at least mild, passive suicidal ideation at some point in their lives.

The authors detailed several hypotheses:

1. Suicidal ideation would be associated with frequency of solitary heavy drinking but not social heavy drinking, controlling for the effects of depression
2. Solitary heavy drinking would be associated with drinking to cope with negative emotions
3. Social heavy drinking would be associated primarily with drinking to enhance positive emotions

So, the picture that the authors anticipated seeing was as follows: individuals who drink heavily alone will be more likely to think about suicide than will individuals who drink heavily with peers, and this situation will not be better accounted for by symptoms of depression.  Additionally, individuals who drink heavily alone will report that their drinking is motivated primarily by the desire to diminish negative emotions whereas individuals who drink heavily in social contexts will report that their drinking is motivated primarily by the desire to enhance positive emotions.

48.4% of the sample reported that they had drank alone at least once in the past month, while 25.3% of the sample reported drinking heavily while alone during that time period.  Individuals who reported solitary heavy drinking engaged in heavy drinking 62.8% more frequently than did individuals who reported only social heavy drinking.  

Suicidal ideation but not depression was associated with solitary heavy drinking.  In other words, the more often an individual drank heavily while alone, the more they thought about suicide (depression levels, however, were not impacted by the frequency of solitary heavy drinking).  Neither depression nor suicidal ideation demonstrated a significant relationship with social heavy drinking.  Drinking heavily with peers was associated only with enhancement motives, whereas drinking heavily while alone was associated only with coping motives.  So, all of the authors' hypotheses were supported by the data.

What does this tell us?  Primarily, it highlights the danger of solitary heavy drinking, as such behavior was highly associated with thoughts of suicide.  Additionally, it demonstrated that heavy solitary drinking is typically motivated by the desire to reduce negative emotions, a motive previously linked to problematic outcomes.  Importantly, these findings do not indicate that all individuals who drink while alone will think of suicide or that individuals who drink with peers are immune to suicidal ideation.  They simply point out that drinking heavily while alone is more frequently associated with problematic drinking outcomes and suicidal ideation than is drinking heavily with peers.

There were a couple of surprising findings in this study.  First of all, the fact that depression was not associated with drinking heavily alone is inconsistent with what I expected to see.  The correlation between depression and suicidal ideation was substantial, so I do not believe this reflects problematic data, but the finding is nonetheless contrary to expectations.  Additionally, it is somewhat surprising that drinking motivated by social reasons was not associated with drinking heavily in social contexts.  This might simply mean that social motives predict social drinking, but only when drinking is motivated by the desire to enhance positive emotions does that drinking escalate to "heavy" levels.

One of the underlying points of this study - that drinking alone is associated with increased suicidal ideation - is consistent with Joiner's interpersonal-psychological theory of suicidal behavior, as one of the components of the desire for suicide in that model is "thwarted belongingness," which is defined by a sense on the part of an individual that he or she lacks meaningful connections to others.  Drinking heavily alone may, in fact, reflect that particular individuals who are upset feel that they do not have social resources to which they can turn.  As a result, those individuals develop the belief that they are left to drink on their own and this isolation could no doubt lead to thoughts of suicide.

Ultimately, perhaps the greatest contribution of this study is a reminder that not everyone who engages in a particular behavior does so for the same reason and that the reason for engaging in a behavior is an important consideration (remember, this applied in our discussion of Nock and Prinstein's functional model of non-suicidal self-injury as well).  Additionally, the context within which an individual utilizes a behavior is important to consider and, the more often the behavior is engaged in alone in a secretive manner, the greater the likelihood that the behavior will be associated with problematic outcomes.

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If you would like to learn more about suicidal ideation and behavior, we recommend the following items, each of which is available through our online store for scientifically-based psychological resources:

• Why People Die by Suicide by Thomas Joiner

• The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients by Thomas Joiner, Kim Van Orden, Tracy Witte, and David Rudd
  

• Treating Suicidal Behavior: An Effective, Time-Limited Approach by David Rudd, Thomas Joiner, and Hasan Rajab

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Advances in addiction treatment: A new podcast

by Joye C. Anestis, M.S.

Alcohol and substance abuse/dependence, or addiction, touches almost all of our lives in some ways.  In the mental health community, discussions of the treatment of addictions are rife with controversy.  But common knowledge of these controversies is minimal - few people outside of the mental health world know that, for example, many problem drinkers can manage their drinking via moderation without entering an inpatient rehab facility (i.e., abstinence is not the only option for many) or that research does not exist to indicate that Alcoholics Anonymous is the most effective self-help treatment available.  Our friends at the Cognitive-Behavioral Therapy Center of Western North Carolina have kicked off their new podcast series with a fascinating discussion of the current state of addiction treatment research, with R. Trent Codd, Ed.S., of the Cognitive-Behavioral Therapy Center of Western North Carolina interviewing Dr. Tom Horvath.  This resource is designed to provide evidence-based information for both professionals and consumers. 

Some of the topics covered in their discussion are:

• The stepped-care approach to addiction treatment. Resources recommended for individuals beginning to investigate treatments include www.moderation.org and www.smartrecovery.org.

• A description of SMART recovery, an alternative to 12-step programs, which combines cognitive-behavioral therapy and motivational enhancement therapy in a self-help format.

• Discussion of the evidence (or lack thereof) behind Alcoholics Anonymous (AA) and other 12-step programs.

• The usefulness of the disease model of addiction

• Medication options available to help those with substance abuse/dependence problems

• Recommendations for family of those struggling with addiction

Several things are worth noting about this particular podcast.  One of the overall messages I felt was conveyed throughout the interview was the importance of motivation on the part of the individual struggling with addiction.  Copious amounts of research has repeatedly shown that addiction treatments don't work unless the addicted individual is motivated for treatment.  In other words, if you don't want to quit, you're not going to quit.  Sounds so obvious, right?  Unfortunately, many folks are of the mindset that staging an intervention (like those showcased on the TV show "Intervention") and then forcing an individual into an inpatient program is the the only way to go.  Such forced treatment fails more times than it works.  One of the key components of developing motivation in an addicted individual is to allow them to choose what type of treatment to pursue, and one of the highlights of this interview is the discussion of the several treatment options that are currently available and well-supported by research literature. 

Another idea that Horvath mentions that I found to be quite exceptional arises during discussion of several controversial topics in addiction, such as the utility of AA and the disease model of addiction.  His take-home message regarding such topics is that, if something is working for you, by all means keep doing it.  For example, there is inadequate literature on the efficacy of AA, even though it is often presented as the best and only option available for folks with alcohol problems.  But this paucity of literature doesn't mean that it doesn't work for some people, and if it does work, then, as they say, "keep coming back." 

Relatedly, viewing addiction as a disease is not supported by what we know about how addiction actually works.  For many people, viewing addiction as a disease decreases their motivation because they feel like they are powerless to change.  But others find comfort and help in that viewpoint - and again, Horvath notes, if it works for you, stick with it. I think it sometimes gets lost when discussing empirically-supported treatments that occassionally treatments with minimal support do work for some folks.  The EST message is never that ESTs are the only things that work, just that they are the only things we can "prove" work for most people with a particular problem. 

So, check out the podcast at www.behaviortherapist.com.  I'll let you know when the next one appears.  For more information on addiction, we recommend the APA Division on Addictions website.  Also, peruse our bookstore for more information on empirically-supported addiction treatments:

• Motivational Interviewing, Second Edition: Preparing People for Change
  

• Motivational Enhancement Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals With Alcohol Abuse and Dependence
  

• Cognitive Therapy of Substance Abuse

• Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening.

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.

Motivational interviewing: Developing intrinsic motivation for change

by Michael D. Anestis, M.S.

I often have a difficult time watching films and television shows that depict psychotherapy.  This is true for a variety of reasons: the tendency to make-up disorders, the tendency to depict bizarre ineffective or even harmful therapeutic approaches (e.g., "rebirthing"), the tendency to depict therapists having inappropriate relationships with clients, and many others.  One particular aspect of popular media presentations of therapy that absolutely horrifies me is the frequent display of confrontational interventions in which an individual is told about all of the horrific consequences of his or her actions and change is demanded.  Theoretically, I can see why this is appealing to some - it lets people victimized by somebody else's behavior express themselves and provides what might seem to be some sort of "eureka" moment in which the poorly behaved individual suddenly realizes the gravity of the situation and becomes inspired to change.  Here's the problem: such approaches, far more often than not, do not work.

Perhaps the most important question then is: why do confrontational interventions not seem to live up to their expectations?  William Miller and Stephen Rollnick, the creators of motivational interviewing (MI), argue that the most significant obstacle is ambivalence.  Individuals with a substance use disorder (SUD), for instance, may see reasons why they want to quit, but also may see reasons why they do not.  It could be that they enjoy using the substance, that the threat of withdrawal seems daunting enough to diminish the threat of the consequences of continuing to use, or any of a number of other reasons.  This is not to say that the reasons for continuing a harmful behavior are reasonable, but rather, that they exist and, as long as the individual feels little to no motivation to change on their own (intrinsic motivation), they are unlikely to follow through on an effective plan for change.  Motivation from within, Miller and Rollnick argue, is essential.  Motivation from external resources (e.g., family members), on the other hand, is less likely to induce long-standing change.

This bring us to Miller and Rollnick's solution to ambivalence - motivational interviewing.   MI is a program for behavior change highly consistent with the tenets of self-determination theory (SDT).  SDT argues that, by making an individual feel more autonomous, outcomes can be improved.  With respect to therapy, autonomy is developed through perspective taking, choice provision, and rationale provision.  Perspective taking involves acknowledging how the client feels and why they feel compelled to behave the way they do.  Notably, this acknowledgment does not involve judgment or the endorsement of bad behavior but rather simply points out that there are reasons why bad behaviors have been sustained and that the therapist recognizes this.  Choice provision involves presenting the client with all potential options for treatment.  From a scientific standpoint, this means presenting the client with a list and description of all empirically supported treatments (ESTs) for their particular diagnosis or diagnoses and leaving the final selection of which therapeutic approach to use up to the client.  Rationale provision involves explaining to the client exactly why certain decisions must be made when choice is not available.  For instance, providing the client with thorough, careful, accurate diagnostic feedback and a description of the evidence supporting specific treatments for that disorder would be necessary in order to explain why other diagnoses and treatment options are not provided.

MI itself involves two stages:

1. Building a commitment to change
2. Developing a plan for change

It is important that the therapist not transition to step 2 too early.  As such, frequent evaluations with assessment tools that measure motivation to change and discussion of these assessments are key.  In order to accomplish the goals of these two stages, MI maintains a series of theoretical stances.  These include:

• An emphasis on the expression of empathy.  The therapist should explain that ambivalence towards change is, in fact, the norm, rather than a sign of a deep character flaw.  In doing this, the client can quickly learn that the therapist is a collaborator willing to listen to his or her perspective.  One particularly effective tool for demonstrating empathy in therapy through an MI framework is reflective listening.  A classic Rogerian tool, reflective listening involves repeating statements by the client back to them with slight variations.  In other words, if the client says "my world has just seemed very dark and hopeless lately," the therapist might say "you've been feeling upset lately and the world does not seem to be offering you any clear light at the end of the tunnel."  Reflective listening is one of those tools that, prior to practice, might seem likely to come across as awkward or insincere; however, in real world practice, therapists quickly learn that it is actually readily accepted by clients and fosters an immediate sense on the part of the client that the therapist is, in fact, listening to what they have to say.

• A non-confrontational development of a discrepancy between the client's current behavior and his or her goals and self-image.  This facet of MI can take many forms, but it often centers around the provision of data.  In some cases, data refers to normative numbers (e.g., percentage of undergraduate students who consume as much alcohol as the client reports consuming).  In other cases, data refers to the collection of new information through self-monitoring (e.g., the client notes every time they engage in the target behavior in order to determine whether their beliefs about frequency/severity match reality).  Here again, the client is not confronted with numbers.  Instead, the therapist should ask the client his or her opinion on the numbers, present objective data, and ask the client for his or her take on any discrepancy.  Another method for developing discrepancies is through amplification, a form of reflective listening.  In this case, rather than directly reflecting the client's statement, the therapist exaggerates or adjusts the tone of the statement.  For example, if a client referred to therapy for alcohol abuse after a DUI arrest says "drinking just isn't a problem for me," the therapist might say "you have never gotten in trouble as a result of drinking."  The therapist must be extremely careful with his or her tone when using this skill, as any sense on the part of the client that the therapist is being condescending, judgmental, or mocking will be detrimental to treatment.

• Avoidance of any arguments or confrontations.  Miller and Rollnick argue that pushing a person to one perspective will cause them to defend the other perspective.  In other words, if you push, they will push back.  Wanting somebody to want something does not make them actually want it.  As such, rather than creating an environment in which the therapist serves as the representative of one side of an argument and the client serves as a representative of the other side, MI works to develop a sense that two individuals, the therapist and the client, are working together to assess a situation and determine if change is desired and, if so, precisely what changes are desired and how they will be attained.

• Rolling with resistance.  Similar to the previous point, rolling with resistance involves decreasing the strength of language or any forceful urging by the therapist when the client resists.  As such, MI views it as beholden upon the therapist to recognize the degree to which the client overtly desires change and to work with him or her at a level consistent with that desire.  Pushing any harder or criticizing resistant behaviors, while natural inclinations, simply are not effective methods for effecting change.  As such, an emphasis is placed on positively reinforcing change statements and positive behaviors rather than punishing resistance.

• Supporting self-efficacy and change statements.  When a client makes any statement that indicates he or she desires to make a positive change, the therapist must leap at the opportunity to positively reinforce such behavior.  Obviously, the tone of the reinforcement should be age appropriate and the level of enthusiasm should be within a range that prevents the client from feeling uncomfortable, but ultimately, such statements are believed to be the mechanism through which MI works and, as such, the therapist must use the most effective means for maximizing their natural occurrence. 

MI can be an extremely brief stand alone intervention - Project MATCH demonstrated efficacy for a 4-session MI intervention in the treatment of alcohol abuse (Finney & Moos, 2002) - or it can serve as an adjunct to other treatments when the client exhibits treatment resistant behaviors (e.g., missed appointments, incomplete homework).  Research has demonstrated preliminary efficacy for MI in the treatment of alcohol abuse, heroin abuse, smoking, HIV risky behaviors, pain management, diabetic treatment adherence, and gambling (Hodkins, Curry, & el-Guebaly, 2001; Miller, 1996).  APA Division 12 does not currently list any treatments for substance use disorders, the diagnoses for which there is the strongest empirical support for MI; however, future updates to the list will likely include MI due to the wealth of evidence for its utility in treatment.

Importantly, MI takes the stance that some individuals are ready for change at a particular moment and others are not.  The therapist can work with the client to utilize his or her own intrinsic motivation, but they can not make an individual want to change, at least not in a sustainable sense.  There are certain to be exceptions to this; however, without any systematic method for identifying such exceptions, the general rule must stand. 

The information above represents a very brief introduction to the basic structure of MI; however, such a brief description necessarily requires minimal coverage of much of the theoretical framework and research behind the treatment.  In future posts, we intend to present more detailed information on MI.  In the meantime, we would love to hear about your experiences with MI, your impression of it as a therapist, client, or general reader, any questions you have regarding why such an approach would be effective, or any other topic relevant to MI.

If you would like to learn more about motivational interviewing, there are several potentially valuable resources available.  Sheldon, Williams, and Joiner (2003) provide a coherent description of MI in a chapter in the book Self-Determination Theory in the Clinic: Motivating Physical and Mental Health.

Additionally, you can read Miller and Rollnick's description of MI and a step-by-step description of how to implement this intervention in their book Motivational Interviewing, Second Edition: Preparing People for Change.

Additional resources include:

• Motivational Interviewing in Health Care: Helping Patients Change Behavior

• Motivational Interviewing in the Treatment of Psychological Problems

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.

Do particular people respond better to certain alcohol treatment approaches?

by Michael D. Anestis, M.S.

Late last week, a comment by "Jan"  in the comments section of an article on the UPPS-P Impulsive Behavior Scale got me thinking about today's topic.  She asked if individuals respond differently to different treatments for alcohol use disorders (AUDs) depending either upon their drinking motive or their respective level of positive or negative urgency.  The short answer to this question is frustrating: nobody knows because we do not have that precise data.  Rather than leave it at that, however, it seemed to me like this comment justified a more thorough look into what we do know about matching clients to particular treatments for AUDs.

By far the most comprehensive effort to answer this question has been Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), a multi-site study in which participants were randomly assigned to one of three treatment approaches: cognitive behavioral coping skills therapy (CBT; Kadden et al., 1992), motivational enhancement therapy (MET; Miller et al., 1992), or twelve step facilitation therapy (TSF; Nowinski, Baker, & Carroll, 1992).  The phrase "random assignment" refers a process by which participants are assigned to a condition (a type of therapy in this case) arbitrarily rather than basing that assignment on preference, severity of presenting problem, or any other variable.  By using random assignment, the authors vastly increase the likelihood that there are no meaningful differences between the groups on variables that could effect the outcome.

Participants took part in one of two parallel studies, one utilizing outpatient clients seeking treatment for AUDs, and the other utilizing a sample of individuals in aftercare following inpatient or outpatient treatment.  The researchers who designed Project MATCH had several hypotheses, but they were primarily interested in answering two questions: 

• Does one of the three treatment approaches utilized in this study stand out as producing greater effects? 

• Are there specific variables that can be used to determine whether an individual would benefit more from one treatment approach rather than another?

Jan's comment was most directly related to the second question, although the first question is an important consideration as well, because if one treatment is significantly better than the other two in general, there is less likelihood that individual difference variables would differentially predict treatment response across therapeutic approaches.  The Project MATCH results and subsequent answers to these questions were both surprising and controversial.  The authors found that all three treatments were equally effective, although individuals in TSF improved more on a variety of secondary variables (Finney & Moos, 2002).  Additionally, they did not find robust evidence supporting the notion that particular patient variables would provide information regarding the best treatment approach for particular individuals (Project MATCH Research Group, 1997).

The variables utilized as the focus of the matching hypothesis were as follows:

• Severity of alcohol involvement
• Cognitive impairment
• Client conceptual level
• Biological sex
• Meaning seeking
• Motivational readiness to change
• Psychiatric severity
• Social support for drinking versus abstinence
• Psychopathy
• Typology
• Anger
• Antisocial personality
• Assertion of autonomy
• Psychiatric diagnosis
• Prior engagement in Alcoholics Anonymous (AA)
• Religiosity
• Self-efficacy
• Social functioning

These variables were chosen based upon a review of prior studies that indicated their potential utility in matching clients to particular treatments.  As mentioned above, these variables did not prove useful in determining who was most likely to respond to which treatment.  The authors themselves noted several reasons why this might have occurred, and to answer Jan's comment, I would like to discuss some of those reasons.

First, it is entirely possible that either the treatments or matching variables chosen by the Project MATCH Research Group are not ideal for matching clients.  Personally, I think this is, for the most part, a highly probable idea.  By no fault of the authors, neither drinking motives nor positive and negative urgency were the subject of much if any research at the time that this project was conducted.  As such, they were not included in the study and no data is available to determine if why an individual drinks influences the manner in which he or she will respond to a particular treatment.  This is not to say that these variables certainly will predict differential treatment response, but it seems like a possibility that justifies further investigation.

Another potential explanation for these findings is that, despite its efforts to understand the utility of matching clients to particular treatments, Project MATCH did not actually match clients to treatments.  As mentioned earlier, random assignment was utilized in an effort to ensure minimal risk of between group differences resulting in spurious findings.  A noble methodological approach in general, in this case random assignment meant that clients were not actually matched to the therapies that were hypothesized to be the most likely to help them.  Comparing a matched sample to a sample randomly assigned to treatment would better serve to answer this question.

As mentioned by Heather (1999) in one of a series of commentaries on Project MATCH published in the journal Addiction, participants in all three conditions attended AA meetings, including those assigned to the TSF treatment condition, which was based on AA.  As such, participants in the TSF condition - who demonstrated greater benefit on secondary variables - actually received, on average, a greater dose of their assigned treatment than did individuals in either the CBT condition or the MET condition.  Given that one of the reported findings for this project is that the greater the number of sessions attended, the greater the effect of the treatment, this seems to potentially serve as a confounding problem that obscures the favorable findings for TSF.

Two others problems with Project MATCH were mentioned by Heather (1999), although he did not believe that they were necessarily as problematic as others believe them to be.  First, abstinence was the sole outcome variable utilized in the study.  In other words, moderation goals, which are particularly prominent in MET, were not considered in assessing the efficacy of the treatment.  The presumption that abstinence alone is the marker for efficacy is subject to debate that is beyond the scope of this particular article.  Additionally, Heather (1999) noted that there was no control group utilized in this study.  Without a waitlist or treatment as usual control group, there is no way to determine the degree to which any of the three treatment approaches actually exhibited an impact above and beyond the effects of what would happen with any other approach or even the lack of any approach whatsoever.  This is not to say that it is likely that the findings were spurious in this sense, but rather it points out that we simply can not determine how this sample compares to others, as we have no easy metric with which to compare them.

So, bringing this back to the central focus of this article, what can we conclude about matching clients to particular treatments for AUDs based upon specific variables?  This deserves a two-part answer.  First, the data we do have does not support the matching hypothesis.  Second, we do not have data that examines whether drinking motives or positive or negative urgency might impact the degree to which an individual responds to a particular treatment.  Personally, I believe that individual difference variables such as negative urgency and drinking motives could serve as informative tools for determining treatment response, but until such data exists, my opinion on that is not a useful guide.  Hopefully, investigations into the use of treatments such as dialectical behavior therapy (DBT; Linehan, 1993) will be conducted in a manner that allows for treatment matching hypotheses to be tested, but until then, we are unfortunately left guessing regarding the answer to Jan's thought provoking question.

If you would like to learn more about the treatment methods utilized in Project MATCH, or treatment methods that are similar, we recommend the following products, all of which are available through our online store:

Motivational Interviewing

Books: Motivational Enhancement Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals With Alcohol Abuse and Dependence ; Motivational Interviewing, Second Edition: Preparing People for Change
Kindle: Motivational Interviewing, Second Edition: Preparing People for Change
DVD: Motivational Interviewing with William R. Miller (Individual Version)

Cognitive Behavioral Therapy

Books:Cognitive-Behavioral Coping Skills Therapy Manual Volume 3 ; Handbook of Cognitive-Behavioral Therapies, Second Edition ; Cognitive Therapy of Substance Abuse
Kindle:Cognitive Therapy in Clinical Practice

Twelve Step Facilitation/Alcoholics Anonymous

Books:Twelve step facilitation therapy manual : A clinical research guide for therapists treating individuals with alcohol abuse and dependence  ; Alcoholics Anonymous - Big Book 4th Edition

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.

Why we drink: A discussion of the Drinking Motives Questionnaire

by Michael D. Anestis, M.S.

A behavior can often look very different across different individuals.  Some individuals differ in the frequency of a particular behavior whereas others differ on the severity of that behavior.  As we have discussed in reference to non-suicidal self-injury (NSSI), some individuals also differ on why they engage in a behavior.  This point is relevant to all behaviors, although research on this last point - motivation for a behavior - has proven especially fruitful in understanding alcohol consumption.  In an effort to better understand motivations for alcohol use, Cooper (1994) created the Drinking Motives Questionnaire - Revised (DMQ-R), which breaks alcohol use into four motivational components:

• Drinking to cope with negative affect
• Drinking to enhance positive affect
• Drinking to be sociable
• Drinking to conform to a group

If you read our earlier article on Nock and Prinstein's (2004) functional model of NSSI, you might notice a fairly strong overlap with these categories.  The first two motives would correspond to intrapersonal negative and positive reinforcement respectively, whereas the second two would loosely correspond to interpersonal positive and negative reinforcement respectively.  Importantly, each of these motivations for drinking predicts different outcomes and corresponds differently to different DSM-IV-TR disorders.  In other words, the act of drinking is important on its own; however, the motivation for drinking provides additional pivotal information regarding the potential outcomes of drinking, severity and duration of drinking, and vulnerability to particular mental illnesses.  A summary of all of the research that has utilized the DMQ-R would be beyond the scope of this particular article, but I would like to provide a basic explanation of what we know regarding different alcohol consumption motives.

In an early experiment examining the impact of drinking motives, Birch and colleagues (2004) found that motives heavily impact individuals' expectations for the potential effects of alcohol consumption.  Specifically, they found that individuals who drink to cope with negative affect experienced an increased belief that alcohol is capable of performing this function when they took part in a negative mood induction.  Similarly, individuals who drink to enhance positive affect experienced an increase in their belief that alcohol consumption could perform this function when they took part in a positive mood induction.  In a later study examining a similar phenomenon, Birch and colleague (2008) found that, after taking part in a positive mood induction, individuals who drink to enhance positive affect demonstrated increased implicit alcohol cognitions.  Field and Powell (2007), meanwhile, found that individuals who drink to cope demonstrated an attentional bias for alcohol cues when experiencing stress.  As such, an individual's motives for drinking alcohol appear to impact thoughts and attention at a basic level during high levels of stress and emotion.

Drinking motives have also been linked to personality variables.  Theakston, Stewart, Dawson, Knowlden-Loewen, and Lehman (2004) found that drinking to cope with negative affect was predicted by low emotional stability, whereas drinking to enhance positive affect was predicted by high levels of extraversion and low levels of conscientiousness.  Similarly, Cyders and Smith (2007) found that positive urgency - the tendency to act rashly when experiencing positive emotions - predicted enhancement motives whereas negative urgency - the tendency to act rashly when experiencing negative emotions - predicted coping motives.  Anestis, Selby, and Joiner (2007) found that residual change in negative urgency over six weeks predicted residual change in coping motives.  Personality types are known to be fairly stable, highly heritable variables.  As such, if specific personality types increase the likelihood of individuals maintaining particular drinking motives, vulnerability to problematic motives may be established long before an individual ever takes his or her first drink.

Chalder, Elgar, and Bennett (2006) examined whether having an alcoholic parent influenced the drinking motives of adolescent drinkers.  They found that adolescents with alcoholic parents were more likely to drink to cope with negative affect.  Similarly, Agrawal and colleagues (2007) examined the degree to which drinking motives are heritable.  The authors found that, while there is no evidence of heritability in drinking to enhance positive affect, conformity, social, and coping motives for drinking are all highly genetically based.  These are important findings because drinking to cope with negative affect is predictive of more problematic drinking outcomes (Cooper, Russell, Skinner, & Windle, 1992).  Specifically, whereas enhancement motives predict the greatest levels of frequency and quantity of alcohol consumption, coping motives predict the greatest level of alcohol abuse symptoms.  As such, certain individuals might be genetically predisposed to consuming alcohol for problematic reasons.

Alcohol motives have also been implicated in specific DSM-IV-TR diagnoses.  Tragesser, Trull, Sher, and Park (2008) found that enhancement motives mediated the relationship between cluster B personality disorder (borderline, narcissistic, histrionic, and antisocial personality disorders) symptoms and alcohol use disorders.  In other words, while there was a significant relationship between symptoms of cluster B personality disorders and alcohol use disorders, this relationship was explained by the high rates of enhancement motives in that particular population.

Perhaps the most frequently researched diagnosis with respect to drinking motives is social anxiety disorder; however, the research on this has yielded conflicting results.  Lewis and colleagues (2008) found that both coping motives and conformity motives mediated the relationship between social anxiety disorder and negative consequences of drinking.  Additionally, Stewart, Morris, Mellings, and Komar (2006) found that both coping motives and conformity motives mediated the relationship between fear of negative evaluation (the primary symptom of social anxiety disorder) and drinking problems.  In contrast, Buckner, Schmidt, and Eggleston (2006) found that enhancement motives mediated the relationship between social anxiety and alcohol problems.  Ultimately, more research on this topic is needed before we can fully understand the role of specific drinking motives in social anxiety disorder.

As the above mentioned findings hopefully make clear, an individual's motivation for drinking provides a substantial amount of information regarding that person's personality, likely style of drinking, response style to emotional experiences, and vulnerability to particular mental illnesses.  As such, just knowing that an individual drinks, even if that person drinks often and heavily, might not be enough.  Consider this from a standpoint of treatment.  If an individual drinks heavily, but does so to enhance positive emotions, might he respond differently to different treatments than would an individual who drinks to reduce negative emotions?  Hopefully future research will answer this very question.  In the meantime, considerations of drinking motives will likely continue to be the subject of considerable research and we look forward to reading the results of such studies.

It is important to consider that these are not the only findings on drinking motives, but rather, a short summary of findings that have utilized a specific measure: the DMQ-R.  Research has shown that this measure is a valid assessment tool for drinking motives across a variety of cultures (Kuntshe, Stewart, & Cooper, 2008), thus indicating that it is an ideal candidate for use in studies seeking to examine this concept.  Some researchers have suggested that coping motives should be parsed into two separate factors - coping-depression and coping-anxiety - so the scale itself may evolve in coming years (Grant, Stweart, O'Connor, Blackwell, & Conrod, 2007); however, the basic structure is unlikely to change substantially.

If you would like to learn more about alcohol use disorders and their treatment, we recommend the following products, all of which are available through our online store:

Books:

• Motivational Interviewing, Second Edition: Preparing People for Change

• Addiction and Change: How Addictions Develop and Addicted People Recover (The Guilford Substance Abuse Series)

• Rethinking Substance Abuse: What the Science Shows, and What We Should Do about It

• Cognitive Therapy of Substance Abuse

DVD:

• Motivational Interviewing with William R. Miller (Individual Version)

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.